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Planning the Change…SMART Goals, Process & Outcome Measures
Bonnie Horvath, MHSA, FACHE, CSSGB
Charlotte Gjerloev, BSN, RN
June 30, 2021
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Who’s Around
the Virtual Table
Objectives
Explore the Model for Improvement
Discuss SMART Goals
Review development of outcome and process measures
Three Fundamental QuestionsFrom the Model for Improvement
Goal Statement
Measure
Change
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Setting the Stage… Developing SMART Goals
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Developing Goals and Measures
Dissecting Your Data toGet to the Root Cause
Your Observations and Questions
Observation
Stage 2 consistently developing
Stage 1 being
missed
Question
Occurring on a specific unit, team?
Is it a specific type of resident?
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What Would Your SMART Goal Be?
Sample Goals
To reduce in-house acquired PI by 20% on West Wing in 3 months.
To reduce number of residents with an in-house acquired PI by 6 in 3 months.
A Balanced Set of Measures Shows If You Are Improving
Outcome Measures
Balancing Measures
ProcessMeasures
Outcome Measures…Where Are We Ultimately Trying to Go?
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• Outcome measures tell you whether changes you are making are actually leading to improvement
2• These are the measures you ultimately
want to move
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• They tell you how the system is performing—what is the ultimate result?
Outcome Measures CouldLook Like This…
Outcome Measure
• Percentage of residents developing a Stage II or Stage III pressure injury.
Outcome
Measure
• Percent of residents developing a newly acquired PI
Process Measures…Are We Doing the Right Things to Get There?
1• To affect the outcome measure, you have to improve your
processes
2• Measuring the results of these process changes will tell you
if they’re leading to improvement
3• Are the parts/steps in the system performing as planned?
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Examples of Process Measures
Sample Process Measures
For Falls: 100% residents will have a falls risk assessment
done within 24 hours of admission
Consistent use of appropriate pressure relief devices on
identified high-risk residents
Process Measures Could Look Like This…
Process Measure
• Consistent use of appropriate pressure relief devices on identified high-risk residents
Process Measure
• Percent of newly admitted residents that have a pressure injury risk assessment within one calendar day of admission
Balancing Measures
Are the changes we are making to one part of the system
causing problems in other parts of the system?
Process ChangesMonitor the impact on other measures
Pressure Ulcer MeasuresCould Look Like This…
Outcome Measure
• Percentage of residents developing a Stage II or Stage III pressure injury.
Process
Measure
• Percent of newly admitted residents that have a pressure injury risk assessment within one calendar day of admission.
Balancing Measure
• Percent of staff who are satisfied or highly satisfied working in facility striving to reduce pressure injuries.
Reminders As You Begin Your Improvement Plan
Gather information to provide focus for the project
Seek input from staff about what might improve the process
What are the specific issues to be investigated?
What would be the impact on the organization?
What resources will be required?
In Summary
Goal Statement
Measure
Change
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For More Information
Bonnie Horvath, MHSA, FACHE, CSSGBSenior Director, Healthcare Quality & Patient SafetyProgram Director, DC, DE and MD QIOs(Direct) [email protected]
Charlotte Gjerloev, BSN, RNNursing Home Team Leader(Direct) [email protected]
This material was prepared by the IPRO QIN-QIO, a partnership of Healthcentric Advisors, Qlarant and IPRO, serving as the Medicare Quality Innovation Network-Quality Improvement Organization for the New England states, NY, NJ, OH, DE, MD, and the District of Columbia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 12SOW-IPRO-DE-TA-A5-21-349
